HCC University

SCAN is committed to partnering with our physician providers in offering high quality geriatric care to our members. A significant part of that effort is to assist our providers in the provision of accurate coding that will contribute to the quality of care and support the expected revenue from the Medicare program. To this end, we present the following tools and education for all the physicians and groups providing care to our members.

Monday, November 25, 2019

CMS is providing free Continuing Medical Education through
the completion of online training modules.All modules apply to Medicare
Fee-for-Service Quality Payment Programs.CMS sent the email below to subscribers to Medlearn Matters.If you would like to receive future
notifications directly, you can sign up one the Medlearn
Matters Electronic Mailing List Page.

Learn More About MIPS
and Earn CME Credit with These 2019 CME Modules

CMS has posted 6 continuing medical
education (CME) modules on the Merit-based Incentive Payment System (MIPS). You
can access them by logging into your Medicare
Learning Network (MLN) account or creating one here. Once
logged in, type the name of the module into the search bar at the top of the
website to find it.

The new MIPS CME modules include:

Quality
Payment Program 2019 Overview
– Provides information on the origin and objectives of the program as well
as an overview of the MIPS and Advanced Alternative Payment Models.

Quality
Payment Program Merit-based Incentive Payment System (MIPS): Participation
in 2019 – Details MIPS eligibility and
participation options, including the new opt-in policy, and how to report
MIPS data.

Contact the Quality Payment
Program at QPP@cms.hhs.gov or 1-866-288-8292 (TTY: 1-877-715-6222). To receive
assistance more quickly, consider calling during non-peak hours—before 10
AM and after 2 PM ET.

All of these issues can be remedied, by following the Centers for Medicare and Medicaid Services guidelines for billing of Skilled Nursing Facility guidance, including the correct use of HIPPS codes.

Although CMS allows Medicare Advantage plans to provide services which may not meet the coverage criteria in Fee-for-service (FFS) Medicare, provision of services and submission of an encounter data are two distinct things. So, while coverage may be extended in some cases when FFS guidelines are not met, encounter data must meet FFS billing requirements in order to be processed. And CMS does require that all services must be submitted as encounter data, whether or not CMS covers them.

The importance of correct encounter data cannot be stressed enough. In order for CMS to have an accurate and complete picture of the services provided to our members, encounters must be processed to completion. By and large, that means they must meet the requirements of FFS medicare when they are sent to health plans. This ensures that they will be correctly processed, and that CMS can more accurately assess the care provided to MA members.

If you have questions regarding CMS Encounter Data, contact Michelle Nguyen of our Encounter Data team at MNguyen3@scanhealthplan.com.

Tuesday, May 8, 2018

As you know, CMS now uses a combination of RAPS (Risk Adjustment
Processing System) data and encounter data submitted thru EDPS (Encounter Data
Processing System) as inputs into the payment system for projecting RAFs (Risk
Adjustment Factors), which is a key input to payment model for MAPD (Medicare
Advantage Prescription Drug) health plans. CMS requires that all
encounter data be submitted by MAPD health plans, including services not
covered by CMS in Fee-For-Service (FFS) Medicare.

Due to the growth of payment strategies such as capitation
in MAPD, providers are no longer financially incentivized to provide complete
data as they were in the traditional claims billing process. This has
been a widely identified trend in MAPD professional data, but also occurs in
the inpatient setting which often contains more robust information then other
places of service. Missing encounter data and the growth of the gap in
these data (between MAPD and FFS) has a number of important ramifications for
MAPD:

·It causes inaccuracies in payment because treated conditions are not
reported and therefore not loaded into the payment model

·It suggests a distorted picture of members’ true disease burden as being
lower than the actual

·It suggests incorrectly to CMS that MAPD members are receiving fewer
services than beneficiaries in traditional Medicare (FFS)

Some possible drivers for this under-reporting are:

·Failure to submit data from sub-capitated providers, including hospitals

·The purposeful filtering of encounter data submitted to the plan with
the goal of providing only incremental HCC model data

·Downstream data that medical groups processes as claims are not always extracted
and reported. This is especially true when the groups’ encounter data and
claims data are on different platforms.

·Selective reporting from providers of only risk adjustable diagnoses in
MAPD and only providing a single E&M procedure code so that the encounter
will process

·Submitting reporting from providers of only diagnoses “linked” to a
procedure code for traditional Medicare claims or only the minimum needed for
the claim to process

While there are no mechanisms in traditional Medicare at
present to submit additional diagnosis data (maximums are currently <=8
diagnoses for professional, <=25 diagnoses for institutional), it’s
important to submit all documented diagnoses and procedures for both programs.
In traditional Medicare where there are more diagnoses then 8, we would suggest
that the provider or biller first choose linked diagnoses followed by the
diagnoses that most accurately reflect the need for the visit and evaluations
conducted at that service. Similarly, reporting all CPT/HCPCS codes is
important since it is the only way that CMS can gain an accurate picture of
procedures performed with the goal of trying to understand and compare value
between the programs.

At present we believe that there are a number of systematic
biases that are impacting the accuracy of the view CMS has on the health status
of the entire Medicare population, biasing towards fewer CPT/HCPCS for MAPD and
fewer ICD codes for traditional FFS.

NOTE:

Remember, SCAN’s Encounter and Risk Adjustment provider team
is here to assist you. Please reach out to Michelle Nguyen at MNguyen3@scanhealthplan.com for
assistance.

Thursday, March 29, 2018

Good afternoon, all. Today, we're lucky to have a special guest post, by one of SCAN's Coding Quality Specialists, Megha Patel, CCS, CPC. Megha has done a lot of hard work for us, compiling all the significant changes to the Official Guidelines for Coding and Reporting, beginning with the switch from ICD-9-CM to ICD-10-CM:

ICD -9 to ICD-10
Official Coding Guideline Updates

1.10/01/2015:

ICD-9 to ICD-10 updated October 1, 2015.

·CAD
with Angina: Use combination codes for CAD with Angina, A causal relationship
can be assumed in a patient with both Atherosclerosis and angina pectoris. It
is not necessary to code Angina Pectoris separately.

·Sequelae
of CVA: Weakness due to previous CVA should be coded as Hemiplegia/Hemiparesis.

·Sequelae
of CVA: Hemiplegia/Hemiparesis/Monoplegia identify whether the dominant or non-dominant
side of affected.If provider didn’t
documented dominant or non-dominant, the default is to assume the right side is
the dominant side. If left side affected, the default is non-dominant.

·DM
with Hyperglycemia: Uncontrolled DM, Inadequately Controlled, Out of
controlled, Poorly Controlled should be coded as Hyperglycemia.

·Diabetes
Ketoacidosis: ICD-10 CM does not provide a specific code for Type II diabetic
Ketoacidosis. Assign code E13.10 Other Specified Diabetes with Ketoacidosis as
per Coding Clinic First Quarter of 2013.

2.03/18/2016:

·DM
with Complications Assumed relationship. The guidelines published in the first
quarter 2016 issue of AHA Coding Clinic on pg. 11. According to this
clarification, the subterm “with” in the index should be interrupted as a link
between diabetes and any of those conditions indented under the word “with”.

** The
linkage between diabetes and Osteomyelitis used to be assumed in ICD-9 but it
is not assumed in ICD -10 (10/01/2015-10/01/2016 Not coded). There is no
assumed relationship till October 1, 2016.

3.10/01/2016:

·Uncontrolled
DM: Uncontrolled DM is classified by type and whether it is hyperglycemia or
hypoglycemia. There is no default code for “uncontrolled DM”. Effective Oct. 1,
2016, uncontrolled diabetes can be referenced as Hyperglycemia or Hypoglycemia.

·Hypertension with CHF: Presumes a causal
relationship between hypertension and heart involvement.

·COPD
with Asthma: COPD with asthma only coded as J44.9. If type of asthma not
documented J45.909 should not be coded. “Unspecified” is not type of asthma.

·COPD
with Emphysema: J43.9 Emphysema assigned as Emphysema is specific type of COPD.

·Emphysema
with an Acute Exacerbation of COPD: Assign J43.9. Both codes have Exclude 1
note to each other. J439 is without Chronic Bronchitis and J449 is with Chronic
Bronchitis. Emphysema is type of COPD so Acute Exacerbation of COPD is covers
in J43.9.

Thanks, Megha--for doing all the heavy lifting!

Remember, you can always download the full text of the ICD-10-CM guidelines on our website, at http://hccuniversity.com/asset/154d663f-95bf-4a59-a1fd-a6e4eb7c8477

Monday, March 5, 2018

The January CMS Encounter Data Sweep deadline
has been extended! This is the FINALCMS sweep impacting 2016 DOS (2017 payment) and
requires the submission of encounters for DOS range01/01/2016 à12/31/2016. CMS currently plans a 75% RAPS and Fee for
Service and 25% EDS and Fee for Service blended risk score based on 2016 DOS.

Additionally, TODAY
is the CMS Final Deadline Date for the March CMS Encounter Data Sweep, which requires
the submission of encounters for DOS range 01/01/2017 à12/31/2017. CMS currently plans a 85%
RAPS and Fee for Service and 15% EDS and Fee for Service blended risk score
based on 2017 DOS.

SCAN has one date for you to manage towards
for the January 2018 sweep (2016 DOS):

oAfter
this deadline, SCAN will NOT process any files received for the
March CMS sweep

7 STEPS YOU CAN TAKE TO PREPARE:

Review your SCAN monthly Encounter Submission Reports

March reports were uploaded to the SCAN Encounter Data
Portal on 3/2/2018. The next ESRs will be uploaded the first week of
April 2018.

2.Review
your SCAN Encounter HCC Reconciliation Reports

This report is available to you monthly. If you would
like to utilize this report for the January and/or March Sweep, please
access the EDP SCAN Documents tab -> HCCs and Encounters.

Review your SCAN All DX Reconciliation reports

This report is available to you monthly. If you would
like to utilize this report for the January and/or March Sweep, please
access the EDP SCAN Documents tab -> HCCs and Encounters.

§QUESTION: What is the All Diagnoses (DX)
Reconciliation report?

§ANSWER: A report containing all diagnosis codes
received from your group for dates of service 01/01/2016 -> 12/31/2016 and
01/01/2017 -> 12/31/2017.

This report can be leveraged along with the HCC
Reconciliation report to match up to your database and ensure all of your
encounter data has been sent to SCAN.

Review your SCAN PCN Reconciliation reports

This report is available to you monthly. If you would
like to utilize this report for the January and/or March Sweep, please
access the EDP SCAN Documents tab -> HCCs and Encounters.

§QUESTION: What is the Patient
Control Number (PCN) Reconciliation report?

§ANSWER: A report containing
a list of all the PCNs received from your group for dates of service 01/01/2016
-> 12/31/2016 and 01/01/2017 -> 12/31/2017. The PCN field provides
you with the ID received from you for each encounter (a.k.a. claim ID). You may
reconcile the list of PCNs against your system to ensure that SCAN has received
all of your PCNs. If any are missing on our list that exist in your system,
then you can identify those as needing to be submitted to SCAN immediately

If you are already reconciling against the PCN report,
then continue to do so and provide an update on results as soon as
available.

*The above reports are designed to help
you ensure that all possible encounter data for SCAN members has been sent to
SCAN to meet the CMS health plan cut-off date of May 4, 2018 for the January
Sweep (RAPS only) and March 2, 2018 for the March Sweep.

It is your responsibility to ensure that the file
uploaded is processed successfully. Due to the larger number of files
received during sweep timeframes, it becomes very difficult to provide
1:1 attention on these files. Please
refer to the SCAN ICE file specifications located on the SCAN Encounter
Data portal or you may email me to request the documents to ensure the
success of your file upload.

Send these files sooner than later; please do
not to wait until April 27, 2018 to upload your 2016 DOS files for the
January Sweep (RAPS only). Additionally, please do not wait until
February 23, 2018 to upload your 2017 DOS files for the March Sweep.

ICE files should only be used to submit additional DX
codes or deletes of DX codes.

The January CMS Encounter Data Sweep is
coming to a close. TODAYis the Final Deadline Date to submit the remainder of
your 2016 DOS Encounter Data!This is the FINALCMS sweep
impacting 2016 DOS (2017 payment) and requires the submission of encounters for
DOS range01/01/2016 à12/31/2016.
CMS currently plans a 75% RAPS and Fee for Service and 25% EDS and Fee for
Service blended risk score based on 2016 DOS.

Additionally, we are now 4 weeks away from SCAN’s Final Deadline Date
for the March CMS Encounter Data Sweep, which requires the submission of
encounters for DOS range 01/01/2017 à12/31/2017.
CMS currently plans a 85% RAPS and Fee for Service and 15% EDS and Fee for
Service blended risk score based on 2017 DOS.

SCAN has two dates for you to manage towards
for the January 2018 sweep:

oThis target date
ensures that SCAN has adequate time to complete processing prior to the health
plan cut-off date by CMS

ØSCAN Deadlinefor Provider
Partners: EOB Friday, January 26, 2018

oAfter this deadline,
SCAN will NOT process any files received for the January CMS
sweep

SCAN has two dates for you to manage towards
for the March 2018 sweep:

ØSCAN Target Date for Provider Partners: EOB Friday, January 26, 2018

oThis target date
ensures that SCAN has adequate time to complete processing prior to the health
plan cut-off date by CMS

ØSCAN Deadlinefor Provider
Partners: EOB Friday, February 23, 2018

oAfter this deadline,
SCAN will NOT process any files received for the March CMS sweep

7 STEPS YOU CAN TAKE TO PREPARE:

Review your SCAN monthly Encounter Submission Reports

January reports were uploaded to the SCAN Encounter
Data Portal on 1/5/2018. The next ESRs will be uploaded the first week of
February 2018.

2.Review
your SCAN Encounter HCC Reconciliation Reports

This report is available to you monthly. If you would
like to utilize this report for the January and/or March Sweep, please
access the EDP SCAN Documents tab -> HCCs and Encounters.

Review your SCAN All DX Reconciliation reports

This report is available to you monthly. If you would
like to utilize this report for the January and/or March Sweep, please
access the EDP SCAN Documents tab -> HCCs and Encounters.

§QUESTION: What is the All Diagnoses (DX)
Reconciliation report?

§ANSWER: A report containing all diagnosis codes
received from your group for dates of service 01/01/2016 -> 12/31/2016 and
01/01/2017 -> 12/31/2017.

This report can be leveraged along with the HCC Reconciliation
report to match up to your database and ensure all of your encounter data
has been sent to SCAN.

Review your SCAN PCN Reconciliation reports

This report is available to you monthly. If you would
like to utilize this report for the January and/or March Sweep, please
access the EDP SCAN Documents tab -> HCCs and Encounters.

§QUESTION: What is the Patient
Control Number (PCN) Reconciliation report?

§ANSWER: A report containing
a list of all the PCNs received from your group for dates of service 01/01/2016
-> 12/31/2016 and 01/01/2017 -> 12/31/2017. The PCN field provides
you with the ID received from you for each encounter (a.k.a. claim ID). You may
reconcile the list of PCNs against your system to ensure that SCAN has received
all of your PCNs. If any are missing on our list that exist in your system,
then you can identify those as needing to be submitted to SCAN immediately

If you are already reconciling against the PCN report,
then continue to do so and provide an update on results as soon as available.

*The above reports are designed to help
you ensure that all possible encounter data for SCAN members has been sent to
SCAN to meet the CMS health plan cut-off date of January 31, 2018 for the
January Sweep and March 2, 2018 for the March Sweep.

It is your responsibility to ensure that the file
uploaded is processed successfully. Due to the larger number of files
received during sweep timeframes, it becomes very difficult to provide 1:1
attention on these files. Please
refer to the SCAN ICE file specifications located on the SCAN Encounter
Data portal or you may email me to request the documents to ensure the
success of your file upload.

Send these files sooner than later; please do
not to wait until January 26, 2017 to upload your 2016 DOS files for the
January Sweep. Additionally, please do not wait until February 23, 2018
to upload your 2017 DOS files for the March Sweep.

ICE files should only be used to submit additional DX
codes or deletes of DX codes.

All comments to HCC University blog postings are reviewed for their appropriateness prior to posting. Comments are subject to the following rules, and are posted at the sole discretion of the moderator. These rules are subject to change at any time at the moderator’s sole discretion.

Comments Specifically not Posted:

Comments related to: the competitive business activities of companies or participants; profits, premiums, prices, surcharges, or discounts; endorsement of suppliers; refusal to deal with suppliers; market behavior of any Health Plan; any other topic involving potentially anticompetitive practice; topics related to specifics on incentives or performance bonuses for RA activities; those specifically recommending a RA Solution (i.e., software used for risk adjustment); any other comment that does not advance the discussion of the current topic or is otherwise deemed inappropriate by the moderator.

Comments which may be Posted

All topics of discussion must be based on factual information, for example: Coding rules or guidelines, changes to the model (proposed and finalized),inclusion or exclusion of diagnosis codes in the CMS-HCC or Rx-HCC model, discussion of the annual Advance notice, discussion of the annual Announcement provisions, CMS posted rules related to coding or Risk Adjustment, general questions about medical records, mentions of a specific solution that are integral to the comment (e.g., we use blank report from Ascender to determine _______) which do not constitute an endorsement of the product; Recommendations of other CMS or other tools which are available at no charge to the public (e.g, the American Academy of Family Practice has a good general physical exam template. It can be downloaded at:_______).